Providence Health & Services - Oregon
Organization Active NPI Hospitalist Physician · Medford, OR
NPI 1154675411 · NPPES record last updated Nov 19, 2025
Key facts
- NPI
- 1154675411
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Hospitalist Physician 208M00000X
- Legal business name
- PROVIDENCE HEALTH & SERVICES - OREGON
- Practice address
- 1111 Crater Lake Ave
Medford, OR 97504-6241 - Phone
- (541) 732-5545
- Fax
- (541) 732-5548
- NPI assigned
- Nov 7, 2012
- Organization subpart
- No
Authorized official
- Name
- Donald Wayne Anderson Jr.
- Title
- Assistant Secretary Enrollment
- Phone
- (425) 358-9786
Other NPIs on the same Medicare enrollment 25
Corporate family (same tax ID) 5
Practitioners 9
-
Sara Emily Grunsky, MSN, FNP-C
-
Katherine Anne Liebler, PA-C
-
Cullen Anthony Mack, PA-C
-
Neil M Olsen, MD
-
Mohamed Siyad, MD
-
Sara Elizabeth Walz, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in OR
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040310000315 | OR | Part B Supplier - Clinic/Group Practice | 5294623245 |
Receives reassigned benefits from 200 practitioners 25 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Central Point, OR; Medford, OR; Grants Pass, OR; Eagle Point, OR |
National Provider Directory
- Tax ID family
- Providence Health Services
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Hospitalist Physician |
208M00000X | Yes |
Addresses
Primary practice location
1111 Crater Lake Ave
Medford, OR 97504-6241
Mailing address
PO Box 31001 - 4180
Pasadena, CA 91110-4180
Phone (503) 215-6271
Other names
- PROVIDENCE MEDICAL GROUP SOUTH
- Providence Medical Group - Medford Hospitalists
Other providers in Medford, OR
- Justice Prosis
- Providence Health & Services - Oregon
- Providence Health & Services - Oregon
- Providence Health & Services - Oregon
- Providence Health & Services - Oregon
- Providence Health & Services - Oregon
- Providence Health & Services - Oregon
- Providence Health & Services - Oregon
- Providence Health & Services - Oregon
- Providence Health & Services - Oregon
All providers in Medford, OR · Hospitalist Physician in Oregon
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 19, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.